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Pathogenesis,
Diagnosis, and
Management
of Severe Pelvic
Inflammatory Disease
and Tuboovarian
Abscess
CATHERINE A. CHAPPELL, MD and
HAROLD C. WIESENFELD, MD, CM
Magee-Womens Hospital of UPMC, University of Pittsburgh,
Pittsburgh, Pennsylvania
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894 Chappell and Wiesenfeld
chronic pelvic pain, infertility, and ectopic with PID approximately one third have
pregnancy. This review will focus on acute TOA.12 An increase in the prevalence of
and severe cases of PID, including those TOAs among women hospitalized for PID
complicated by TOA. might be related to increasing frequency
and acceptability of outpatient treatment
of PID, thus leading to hospitalization in
Epidemiology and Risk Factors only severe cases of PID and those with
The incidence of PID correlates with the TOAs.13 The risk factors for TOA are
incidence of sexually transmitted diseases, similar to those of PID, including multiple
which increased in the 1970s and peaked sex partners, age between 15 and 25 years,
in 1982 with an estimated 1 million cases and a prior history of PID. Women with
and 14.2% prevalence of PID treatment human immunodeficiency virus infection
among reproductive-aged women in the may be more likely to develop TOA com-
United States.3,4 However, generally the pared with women negative for human
incidence and prevalence of PID is diffi- immunodeficiency virus.14,15
cult to assess because of the lack of report-
ing requirement for PID, high rates of
subclinical PID, increasing rates of out- Pathogenesis
patient management, and inaccuracies in PID is caused by an ascending infection of
diagnosis. lower genital tract organisms from the
Several risk factors for the develop- vagina or cervix into the upper tract,
ment of PID have been identified, while including the uterus, fallopian tubes, and
others remain controversial. PID is highly peritoneal cavity. Up to 75% of cases
associated with younger age of coitarche, occur during the follicular phase of the
multiple sexual partners, nonuse of bar- menstrual cycle.16 Similarly, a high estro-
rier contraception, and infection with gen environment along with the presence
chlamydia or gonorrhea.5 The Dalkon of cervical ectopy found in adolescence
Shield, an intrauterine device (IUD) that facilitates the attachment of Chlamydia
is no longer available, increased users risk trachomatis and Neisseria gonorrhoeae,
of PID by a wicking effect of its multifila- which may contribute to the higher rates
ment string that allowed microbes to as- of PID among young women.17
cend into the upper genital tract from the TOAs are also caused by an ascending
vagina.6 Modern IUDs do not seem to infection to the fallopian tube causing
increase the risk of development of PID endothelial damage and edema of the
beyond the risk associated with insertion infundibulum resulting in tubal blockage.
of the device.7,8 Case-controlled studies The ovary may become involved presum-
have shown an association between vagi- ably by invasion of organisms through the
nal douching and PID.911 Hypothesized ovulation site. Eventually the separation
mechanisms for this association have in- between the ovary and fallopian tube is
cluded the introduction of vaginal mi- lost. Necrosis inside this complex mass
crobes into the upper genital tract by the may result in 1 or more abscess cavities
force of the douche fluid or the shift of and an anaerobic growth environment.12
protective microbiological flora. A TOA may also form from local spread
It is unclear why some women with PID of infection associated with uncontrolled
develop TOA, whereas the majority of inflammatory disease of the bowel, ap-
women do not. Formation of TOA may pendicitis, or adnexal surgery. It is impor-
be related to prior PID infection, delay in tant to note that TOAs, unlike other
treatment, or virulence factors of the types of abscesses, occur between organs
pathogens.12 Among hospitalized patients rather than confined inside an organ. The
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60% of abscesses >9 cm. DeWitt et al57 of rupture.24 Options for approach can
showed that abscesses >8 cm more often range from imaging-guided drainage to
required drainage or surgery and were laparoscopy to laparotomy. Most gynecol-
associated with longer length of hospital- ogists continue to use the laparotomy as
ization. Thus, it is reasonable to initiate the preferred surgical approach for de-
antibiotics alone in women who are bridement of TOA. However, the laparo-
hemodynamically stable and when the scopic approach seems to be safe in cases
abscess is 8 cm or less in diameter. When where there is no evidence of TOA rupture
clinical response is not achieved within 48 and may have improved outcomes of lap-
hours after initiation of antibiotics, then arotomy, including decreased length of
surgical management or drainage should hospitalization, decreased rates of wound
be considered. In addition, in women with infections, and more rapid rate of fever
an abscess 8 cm or greater immediate defervesce.62 However, the surgical ap-
drainage rather awaiting clinical response proach should depend on the skill and
may decrease duration of hospitalization. comfort of the surgeon. Surgeries for
In addition, aggressive surgical manage- TOAs can be very complicated because
ment should be considered in postmeno- of the extensive adhesions from the abscess
pausal women, because malignancy is a to the surround structures and the necrotic
concern in any postmenopausal woman and inflamed tissues surrounding the ab-
who presents with an abscess.5860 Proto- scess. For this reason, the laparoscopic
papas et al59 reported that 8 of 17 (47%) experience and expertise of the surgeon
postmenopausal women had an underly- cannot be understated. We recommend
ing malignancy as compared with 1 of the removal of the abscess cavity and the
76 premenopausal women (1.3%). Thus, associated necrotic tissue and then irriga-
postmenopausal women with TOA should tion of the peritoneum. We offer hysterec-
be counseled on their risk of malignancy tomy with bilateral salpingo-opherectomy
and potential need for complete surgical to patients who are acutely ill and have
staging. Although the diagnostic yield completed child bearing. This approach
could be lower in these cases due to the may hasten recovery compared with fertil-
significant necrosis of the tissue, a frozen ity-sparing surgery. In addition, this elim-
section of the abscess should be sent from inates the need for repeat surgery that is
the operating room. required in 10% to 20% of women who
Surgical management options for TOAs have more conservative approaches.24,55
range from only drainage to unilateral Since the 1970s, several imaging mo-
salpingo-operectomy to total abdominal dalities and approaches have been used to
hysterectomy and bilateral salpingo-oo- successfully drain intra-abdominal ab-
pherecectomy. Historically, most women scess collections eliminating the need for
with TOA were managed aggressively with surgery.12,63,64 Pelvic abscess have been
a total abdominal hysterectomy and bilat- drained using ultrasound or CT guidance
eral salpingo-opherectomy. Although this with a transabdominal, trangluteal, trans-
approach offered high cure rates, it was rectal, or transvaginal approach. The ap-
at the cost of high rates of surgical com- proach depends on the location of the
plications, infertility, and hormone defi- collection, with most commonly a trans-
ciency.61 With the advent of effective abdominal approach for abscesses in the
antimicrobial therapy, operative manage- upper pelvis or abdomen and a transva-
ment has become much more conservative ginal approach for deeper pelvic ab-
moving toward procedures that allow scesses.65 Abscesses can be drained with
for sparing of ovarian function and if a catheter placement or aspiration alone
possible can even be considered in cases with a success rate ranging between
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